Provider Demographics
NPI:1326562034
Name:MITCHELL, ROGER (DC)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22230 141ST AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11413-2902
Mailing Address - Country:US
Mailing Address - Phone:917-690-4730
Mailing Address - Fax:
Practice Address - Street 1:7 WALNUT RD
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-2267
Practice Address - Country:US
Practice Address - Phone:516-609-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-03
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012994111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor